Saturday, 20 March 2010

The hostel where Daisy had lived for over 15 years decided that they could no longer manage her and gave her notice to quit while she was in hospital. In the event, this was to Daisy’s advantage, as being a vulnerable and potentially homeless person, she was allocated a nice flat away from a hostel environment. When she was recovered, she moved into her new flat, with some community support. She was content. For about 5 years she remained well, although her physical health did not improve. Through her continued obesity, she developed Type II diabetes, and her liking for sweet and fatty foods made it difficult to control. Her legs had become ulcerated, probably because of her poor control of her diabetes. But her mental state remained so stable that the CMHT reduced its involvement to little more than periodic medical reviews with the team psychiatrist and weekly support with practical things such as shopping.

Then her father died. She was understandably upset, but this also served to destabilise her. Over a period of a few months, her manic symptoms returned. By now, her daughter was an adult and frequently visited her in her flat.

One Friday, her daughter came to the CMHT to tell us that she had visited Daisy and had found her mother washing her cups and plates in the washing machine. When she tried to challenge her about this, she explained to her that a Shaman had told her this was the best way to do it, as it would bode well for the future. Daisy had also phoned the RSPCA to report the presence of a five inch diameter spider in her bath (she was very exact about this), and had also reported to the police an attempt to burgle her flat from below (it was a groundfloor flat). She was again spending lots of money on food, and her fridge was crammed with smoked salmon, pate de fois gras, roast partridge, oysters, and champagne. Her daughter had also found her prescription of lithium, with evidence that few had been taken in the last couple of weeks.

Daisy happened to have an appointment with the psychiatrist that afternoon, so I stood by to find out the outcome of this. The psychiatrist popped her head round my door. “I think you’d better come in,” she said.

Daisy was sitting regally in the psychiatrist’s room.

“Oh, hello,” Daisy said when she saw me. “Have you come to section me? I’m not going to hospital, because I will die of a heart attack if I step foot in a hospital. They’re bad places. People are always dying in hospitals. Best to avoid them completely. A Shaman has foretold this. So it will come to pass.”

She continued in this vein for some minutes, despite attempts to ask her questions and discuss the situation with her. Her GP and her daughter joined us, and got no further with her than we had. It was becoming clear that Daisy needed to go to hospital again.

I took her daughter to one side.

“Your mother needs to go into hospital, I’m afraid. She’s clearly not going to agree to an informal admission this time. Since we know her diagnosis and we know she needs treatment, we’re planning to use Sec.3 of the Mental Health Act. As her Nearest Relative under the Act, I need to know if you have any objection to this.”

“Actually, I do,” she told me. “There’s a friend of hers coming this weekend, and mother would be very disappointed if she missed him.”

Her daughter would not be swayed in this. So we could not proceed with an admission under Sec.3 at that point.

We cobbled together a plan for the weekend. Her daughter would try to get her medication into her, and her care co-ordinator would review her on Monday and we would take it from there. The ward were alerted to the possible imminent need of an admission and a bed was reserved

As it happened, things did not go well over the weekend. Daisy would not take her medication, she became so excited by the prospect of her friend visiting that she did not sleep at all, and her mood continued to spiral out of control. Somehow or other, her daughter managed to persuade her to go into hospital, and on Monday she was making her presence felt on the ward.

She remained as an informal patient for about month. Then I received a request to assess her for detention under Sec.3. Although Daisy was showing no signs of wishing to leave the ward, she was also not taking her medication. In addition, she resisted attempts to stabilise her diabetes by refusing to have blood glucose tests or take her diabetic medication.

“Oh, it’s you again, is it?” she said, when I went into her room, accompanied by a female social work student as a chaperone. She was sitting in a chair beside her bed. Her legs had recently been rebandaged, but she seemed intent on loosening the bandages.

“You like me, don’t you? I know you do. That’s why you keep coming to see me. You are undressing me with your eyes. You want to get in my knickers, don’t you? Would you like to see my knickers?”

I was suddenly very glad I was not on my own.

“Daisy,” I said. “I am here, again, to see whether or not you need to be detained in hospital for treatment.

“You are mentally unwell at present. And you’re also physically unwell. You’re not letting the staff help you manage your diabetes. You keep interfering with your bandages on your legs.”

“I don’t need any help with my diabetes. I’ve been taught by a Shaman how to control my diabetes with my will alone. In any case, diabetes does not really exist. It’s only a shortage of sugar in the diet that creates the illusion of diabetes. Everything’s an illusion. These bandages are an illusion. They’re not really there at all.”

“Well, it they’re not really there, perhaps you could leave them alone,” I said, becoming slightly irritated.

“Are you being sarcastic? Because if you are, I shall have to ask you to leave.”

Our conversation continued in this vein for some minutes. It was clear that she was manic, that she was delusional, that she would not accept the treatment she needed, and that her mental illness was also affecting her physical health. She did need to be detained.

But her inpatient stay dragged on and on this time. Her mental state did not seem to improve. In some ways, it seemed to deteriorate.

The hospital gave her a brain scan. The results weren’t good. There was evidence of atrophy in her frontal lobes. She was developing dementia in addition to her mental illness. This would explain her disinhibition.

But there was no treatment for this. And she would continue to deteriorate.

Daisy was eventually placed under Guardianship (Sec.7 MHA) and transferred to a nursing home. Five years on she is still there. She seems to enjoy it there, but still protests that she wants to return to her flat in Charwood, where she would be able to make her diabetes fade away using only the power of her will and a regular supply of doughnuts.

Sunday, 14 March 2010

People with bipolar affective disorder are frequently intelligent and fascinating. They can lead completely normal and often exceptional lives, sometimes with medication and sometimes without. But bipolar disorder can also destroy people. There is no moral to this story, but this is, I am very much afraid, not a story with a happy ending.

I first met Daisy when she was admitted to the local hostel for people with mental health needs in the 1980’s. I was on the management committee at the time. She had a diagnosis of bipolar affective disorder. She was in her thirties and had spent a long time in hospital following an acute manic episode. The illness had effectively destroyed her life. Up until then she had been happily married, with a young daughter, living in a nice house in a nice part of Charwood, and working in the town as an assistant bank manager. She was an intelligent woman who had great ambition. But the onset of bipolar affective disorder had changed all that.

As her mental illness took hold, she became more and more grandiose and disinhibited. Her work suffered. She lavishly spent money she didn’t have on ridiculous schemes. She began to neglect her daughter. She embarked on reckless affairs which put increasing strain on her marriage. Eventually everything imploded and she was admitted to hospital. During her incarceration her husband filed for divorce and got custody of their daughter. He kept the house and she became effectively homeless. By the time she was admitted to the hostel, she was thin and ghostly in appearance, hardly ever saying a word, afraid to look anyone in the eye, and on an extensive medication regime of mood stabilisers and antipsychotics.

Over a number of years, however, I saw her gradually change. Several different combinations and doses of medication were tried, and her personality and something of her old spark began to return. At the regular dinners the committee members had with residents, she began to converse more, and her intellect began to shine through. She was a personable, articulate, well educated and vivacious woman, with good conversational skills. In time, she moved on to a self contained flat attached to the hostel, requiring less and less support.

But then, over 15 years on from her first breakdown, the bipolar disorder began to kick in again, and she became more and more manic. She began to spend large amounts of money on huge quantities of luxury foods which she could not possibly eat, and which was inevitably wasted. Since she had a very good pension from the bank where she had worked, she had accumulated a large amount of savings which she proceeded to squander. She was disinhibited, swearing in a way she would never normally have done, and flirting indiscriminately with males and females alike.

Eventually I was asked to assess her under the Mental Health Act. We arranged for her to come to the CMHT offices. When she arrived the button on her jeans was undone, as was her zip, and her jeans were halfway down her buttocks. She had put on a lot of weight, and much of this was on display. She was completely oblivious to this, and when she saw me she told me to “fuck off” before I could even speak to her, directed an impressive range of swearwords at several invisible people in the room, then walked out again.

I caught up with her again a day or two later, when she came to see her care coordinator at the CMHT. Although Daisy appeared a little less elevated than the day before, she nevertheless spoke rapidly and intensely, and was very difficult to interrupt. I gradually told her that in my opinion she was exhibiting symptoms consistent with hypomania, and listed them, explaining their meaning and the direct evidence I had to support my opinion. These included pressure of speech, flight of ideas, disinhibition -- arising not only from her state of dress yesterday but also from numerous occasions in which she had spoken loudly and inappropriately about her romantic and sexual desires for a male friend of hers, and the reckless spending of money.

“None of that is true, and you know it! I’ll have you for slander. I have friends in the legal profession who will sue you! I’ve only got to ring them!” she told me with the absolute certainty that only the most manic (and deluded) can possess. “If you persist in carrying on in that tone, I shall have no alternative but to hit you across the head!”

“Daisy,” I began, as calmly as possible. “If you were to hit me, it would only confirm my opinion. You would never dream of doing something like that if you were well. I do think you need to be in hospital at present.”

“Well,” she said, “If you’re thinking of sectioning me, I shall just have to jump in front of a lorry! What do you think of that?”

I did not think this was a good idea. However, I also did not think she was likely to carry out this threat.

“Look, why don’t you take a little more medication. You might be able to avoid going into hospital.”

She thought about this – for about a millisecond.

“And why don’t you go and fuck yourself!” she answered.

Her care coordinator decided to contribute to the conversation. “Daisy, that is an idea. I could take you to see Dr Drinkwater [her GP]. Let’s see what he thinks.”

Daisy liked Dr Drinkwater. “He is a very good friend of mine,” she said. “I do trust him. I’ll ask him what he thinks.”

I heard later from her care coordinator that Dr Drinkwater had agreed with me, and had recommended an increase in her medication. Amazingly, she had agreed to this. She therefore avoided a compulsory admission, and in time her manic episode subsided.

Two years later, however, she became manic again. All the symptoms had returned. Once again I was asked to assess her under the Mental Health Act.

She agreed to come and see me at the CMHT, arriving like a galleon in full sail, and walked into an interview, saying, “You can tell that fucker I’m here, and let’s see if he dares to section me.”

I sat down with her. “Hello, Daisy. You know what this is about. You know I have to assess you under the Mental Health Act, and you know I have the power to detain you if I think it is necessary. However, the last time we were in this situation, that didn’t happen, did it?”

“I can’t imagine why you think I need to go to hospital. I’ve asked all my friends, and they all agree that there’s nothing wrong with me.” She proceeded to give me the full details of all the people she had consulted and what they had said, at breakneck speed, so that it was impossible to interrupt her or get a word in edgeways. So I just sat there for a few minutes, waiting for her to stop.

During this monologue something strange and unexpected started to happen. Liquid started to flood from her seat onto the floor all around her. After a moment of shocked surprise I realised that she was urinating. She clearly eventually realised this too. She stopped talking, in order, it seemed, to give it her full attention.

The cascade of urine seemed to be interminable, but probably lasted no more than 4 or 5 minutes. She obviously needed to go. The puddle on the carpet began to extend inexorably towards me. I moved my feet discreetly.

Daisy sat there looking totally unconcerned as steam rose around her and the room filled with a miasma of hot urine. When she had completely finished, and the Niagara of urine had finally abated, she said with immense dignity, “I do have a urinary tract infection, you know,” as if no further explanation were necessary.

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About Me

I am an Approved Mental Health Professional working in a semi-rural area in England. I have practised under 3 Mental Health Acts, since as long ago as 1981, even before the 1983 Mental Health Act. Which makes me pretty ancient now.
This blog is designed to illuminate and explain the functions and dlimemmas of an AMHP within the Mental Health Act. It is intended to be of help to professionals and service users alike. I hope that it is both informative and entertaining.
I am also a freelance trainer, and a part time tutor on an AMHP course. I've appeared at conferences all over England and Wales. If you'd like to book me for your conference or training event just send me an email.